Chest tubes: indications, placement, management, and complications

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.

A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax

BACKGROUND

The optimal initial treatment approach for pneumothorax remains controversial. This systemic review and meta-analysis investigated the effectiveness of small-bore pigtail catheter (PC) drainage compared with that of large-bore chest tube (LBCT) drainage as the initial treatment approach for all subtypes of pneumothorax.

METHODS

PubMed and Embase were systematically searched for observational studies and randomized controlled trials published up to October 9, 2017, that compared PC and LBCT as the initial treatment for pneumothorax. The investigative outcomes included success rates, recurrence rates, complication rates, drainage duration, and hospital stay.

RESULTS

Of the 11 included studies (875 patients), the success rate was similar in the PC (79.84%) and LBCT (82.87%) groups, with a risk ratio of 0.99 (95% CI, 0.93 to 1.05; I² = 0%). Specifically, PC drainage was associated with a significantly lower complication rate following spontaneous pneumothorax than LBCT drainage (Peto odds ratio: 0.49 [95% CI, 0.28 to 0.85]; I² = 29%). In the spontaneous subgroup, PC drainage was associated with a significantly shorter drainage duration (mean difference, -1.51 [95% CI, -2.93 to -0.09]) and hospital stay (mean difference: -2.54 [95% CI, -3.16 to -1.92]; P < .001) than the LBCT group.

CONCLUSIONS

Collectively, results of the meta-analysis suggest PC drainage may be considered as the initial treatment option for patients with primary or secondary spontaneous pneumothorax. Ideally, randomized controlled trials are needed to compare PC vs LBCT among different subgroups of patients with pneumothorax, which may ultimately improve clinical care and management for these patients.

TRIAL REGISTRY

PROSPERO; No.: CRD42017078481; URL: https://www.crd.york.ac.uk/prospero/.

Liver injury secondary to chest tube placement: a case report of conservative management and review of literature

Chest tube placement is a routine procedure performed in different medical departments. Liver injury is a very rare complication that can occur but can be life‐threatening. Conservative management can be proposed in stable patient. Following guidelines and training physicians should decrease the incidence of such complications.

Management of chest trauma

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

Errors and Complications in Chest Tube Placement

Chest drain placement is one of the most common surgical procedures performed in routine clinical practice. Despite the many benefits, chest tube insertion is not always a harmless procedure, and potential significant morbidity and mortality may exist. The aim of this article was to highlight the correct chest tube placement procedure and to focus on errors and clinical complications following its incorrect insertion into the chest.

Complications of chest tubes: a focused clinical synopsis

PURPOSE OF REVIEW

Chest tube placement, or tube thoracostomy, is an invasive procedure designed to evacuate air and/or fluid from the thorax, whether emergent or elective. In the placement of these devices particular attention and effort must be made to understand safe and reliable anatomic techniques and device maintenance so as to avoid serious injury to the patient. This review focuses on complications of chest tube placement, with the emphasis on patient safety and error prevention.

RECENT FINDINGS

There is a paucity of high-quality recent literature on tube thoracostomy complications. With the advent of value-driven healthcare, increasing emphasis is being placed on appropriate procedural indications, procedural safety, and patient satisfaction. Good clinical outcomes are critical to achieve and maintain in this context.

SUMMARY

Given the high volume of tube thoracostomies globally, greater awareness of potential complications and preventive strategies is needed. The authors attempt to bridge this important gap.

Phantom model and scoring system to assess ability in ultrasound-guided chest drain positioning

BACKGROUND

Chest tube positioning is an invasive procedure associated with potentially serious injuries. In the last few years, we have been running a project directed at developing a practical simulator of a surgical procedure taught on our medical training program. The phantom model reconstructs the pleural anatomy, visible by lung ultrasound, used for the assessed performance of the Seldinger technique. The aim of the present study was to investigate the validity of this simulation technology for assessing residents in anesthesia and intensive care medicine; specifically, their skill in positioning a US-guided chest tube drain was tested using the simulator device. The second aim of the paper was to evaluate the learning curve of our residents over their 5-year study course and validate the phantom scoring system.

METHODS

This was a prospective, single-blinded observational study. Participants were recruited from residents in anesthesia and intensive care medicine and divided into two groups: 'Novice' and 'Expert,' based on the course year attended (years 1, 2, and 3 vs. years 4 and 5, respectively). We asked them to position a chest tube drain in a phantom model, guided by ultrasound, to drain a simulated pleural effusion. Each subject performed two tests that simulated pleural effusions of 4 and 2 cm, respectively. Every step of the maneuver was constantly monitored and the performance scored by the investigators. We then performed a Spearman correlation analysis to evaluate the effect of experience level on the performance of the two groups of residents.

RESULTS

Thirty-one residents were included in this study: 20 in the Novice group and 11 in the Expert group. The mean performance rating score was 0.75 ± 4.38 for the Novice Group and 5.91 ± 3.75 for the Expert group (p = 0.0026). The Spearman correlation analysis examining the relationship between year of residency and performance rating score confirmed a positive correlation (r = 0.58, p = 0.0006). Post-test trend analysis revealed a statistically significant linear trend for skill growth across time, i.e., course year (p = 0.0022).

CONCLUSIONS

Our simulated procedure using a phantom model of lung anatomy can accurately and reliably be used to assess the skill levels of operators in their ability to drain pleural effusion.

Pneumothorax in the critically ill patient

Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days.

Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers

BACKGROUND

Emergent placement of a chest tube is a potentially life-saving procedure, but rate of misplacement and organ injury is up to 30%. In principle, chest tube insertion can be performed by using Trocar or Non-trocar techniques. If using trocar technique, two different chest tubes (equipped with sharp or blunt tip) are currently commercially available. This study was performed to detect any difference with respect to time until tube insertion, to success and to misplacement rate.

METHODS

Twenty emergency physicians performed five tube thoracostomies using both blunt and sharp tipped tube kits in 100 fresh human cadavers (100 thoracostomies with each kit). Time until tube insertion served as primary outcome. Complications and success rate were examined by pathological dissection and served as further outcomes parameters.

RESULTS

Difference in mean time until tube insertion (63 s vs. 59 s) was statistically not significant. In both groups, time for insertion decreased from the 1st to the 5th attempt and showed dependency on the cadaver's BMI and on the individual physician. Success rate differed between both groups (92% using blunt vs. 86% using sharp tipped kits) and injuries and misplacements occurred significantly more frequently using chest tubes with sharp tips (p = 0.04).

CONCLUSION

Data suggest that chest drain insertion with trocars is associated with a 6-14% operator-related complication rate. No difference in average time could be found. However, misplacements and organ injuries occurred more frequently using sharp tips. Consequently, if using a trocar technique, the use of blunt tipped kits is recommended.

Chest drain insertion is not a harmless procedure--are we doing it safely?

The incorrect insertion of a chest drain can cause serious harm or even death. All elective drains should be inserted in the 'triangle of safety' in line with the British Thoracic Society guidelines. The aim of this study was to test the awareness of junior doctors involved in inserting chest drains with these guidelines. Fifty junior doctors were questioned. Participants were asked to grade their experience of chest drain insertion and mark on a diagram where they felt was the optimum site for inserting a drain for a large pneumothorax in an elective situation. Only 44% (n=22) of doctors indicated they would insert a chest drain within the safe triangle. Level of experience, seniority and specialty all had an effect on knowledge of the correct site. Of those who had inserted drains unsupervised, 48% (n=16) would site the drain outside the safe triangle as would 75% (n=6) of those who had performed the procedure supervised. Only 25% of medics knew where to insert a drain, compared with 58% of doctors working in surgery. The majority of junior doctors do not have the basic knowledge to insert a chest drain safely. Further training in this procedure is needed for junior doctors.

Video-based Ergonomic Analysis to Evaluate Thoracostomy Tube Placement Techniques

BACKGROUND

Thoracostomy for relief of pneumo- or hemothorax may be performed emergently at the bedside, in the emergency department or trauma area, often in nonideal circumstances. We hypothesized that ergonomic analysis of thoracostomy techniques can identify areas for potential improvement in patient and operator safety.

METHODS

Interviews with Subject Matter Experts (SME) provided steps in the task of thoracostomy; 44 thoracostomies (emergent and elective) were video-recorded and reviewed by SMEs. Ergonomic analyses evaluated surgical performance techniques using video clips.

RESULTS

Risks to the patient and operator included instrument-tray positioning and instrument content. Analyses of video records revealed that despite SME-survey consensus, operators inconsistently followed recommended techniques.

CONCLUSIONS

Discrepancies between SME-recommended and observed practice are prevalent, with simple ergonomic problems impeding performance, and creating risks for patients and operators. Video-based ergonomic analysis is a rich source for identifying task performance problems and potential solutions.

Centromere DNA, proteins and kinetochore assembly in vertebrate cells

The centromere is a specialized region of the chromosome that is essential for faithful chromosome segregation during mitosis and meiosis in eukaryotic cells. It is the site at which the kinetochore, the functional nucleoprotein complex responsible for microtubule binding and chromosome movement, is assembled through complex molecular mechanisms. Herein, I review recent advances in our understanding of centromeric DNAs as sites for kinetochore assembly and the mechanisms underlying kinetochore assembly in vertebrate cells.

[Diagnosis and immediate therapeutic management of chest trauma. A systematic review of the literature]

OBJECTIVE

Injuries to the chest contribute significantly to the morbidity and mortality in multiple injured patients. This systematic review focuses on evidence based initial diagnostics and emergency room management of chest trauma.

METHODS

Clinical trials was systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).

RESULTS

There are only a few studies that document the impact of injury mechanism and clinical examination of the patient. There is a positive correlation between crash severity or lateral impact with injury severity. Auscultation was found to be very sensitive in the detection of pneumothorax. Helical CT of the chest is most important in the initial work-up. Aortography is only indicated in selected cases. Whether tube thoracostomy is necessary in patients with occult pneumotharaces is still a matter of discussion. Indications for endotracheal intubation are poorly investigated and predominantly based on expert opinion.

CONCLUSION

Numerous comparative studies (LE 2) dealing with emergency diagnostics and therapy of chest trauma are available, however only a few randomized studies do exist. Based on the available data a rational therapy of chest trauma is possible.

A review of "chest tubes" during donor care and after transplantation

Thoracostomy tubes, also called chest tubes, are commonly present after transplantation or during donor care. The function of the thoracostomy tube is to provide a conduit for transporting fluid, gas, or blood from the pleural cavity to an attached drainage unit. Malfunction of the tube or parts of the unit assembly may lead to serious consequences and jeopardize transplant recipient recovery or donor organs. This review discusses the components of the thoracostomy tube and drainage unit assembly, normal operation, routine evaluation, and common problems that the organ procurement or transplantation coordinator may need to anticipate or treat.

A Review of “Chest Tubes” during Donor Care and after Transplantation

Thoracostomy tubes, also called chest tubes, are commonly present after transplantation or during donor care. The function of the thoracostomy tube is to provide a conduit for transporting fluid, gas, or blood from the pleural cavity to an attached drainage unit. Malfunction of the tube or parts of the unit assembly may lead to serious consequences and jeopardize transplant recipient recovery or donor organs. This review discusses the components of the thoracostomy tube and drainage unit assembly, normal operation, routine evaluation, and common problems that the organ procurement or transplantation coordinator may need to anticipate or treat.

Modified Seldinger technique for the insertion of standard chest tubes

Closed tube thoracostomy is a standard procedure for the evacuation of air, blood, or other materials from the pleural space. This paper describes a modification of the Seldinger technique that facilitates chest tube insertion. Either a Nelaton or Thieman catheter is threaded into the side drainage hole and out the tip of a standard Argyle-type chest tube. After using the clamp to insert the catheter into the pleural space through a previously dissected tract, the catheter serves as a guide over which the chest tube is inserted. The technique is simple to use, effective, and safe. It employs standard, inexpensive materials to insert chest tubes in such a way as to minimize the potential traumatic complications inherent in other techniques.

Tension Pneumothorax: Etiology, Diagnosis, Pathophysiology, and Management

The normally air-free pleural cavity exists at subatmospheric pressure to promote pleural apposition and proper lung excursion. Owing to its unique bilayer structure, air introduced into this space either from within the thoracic cavity or from an extrathoracic source causes pleural separation and simple pneumothorax (PTX). Most simple pneumothoracies of a small or static volume in healthy patients do not appreciably impair cardiopulmonary function despite variable collapse of the lung. If increasing pressure develops within this pleural air collection, however, a cascade of pathophysiological changes can result from altered anatomical positions of heart, lung, and great vessels. The development of increasing pressure within the pleural space, with resultant ipsilateral lung collapse and hemithoracic expansion into the mediastinum and the contralateral lung, is termed tension pneumothorax (TPTX). The exact incidence of TPTX is unknown, but it is reported in up to 2 to 3% of all pneumothoracies. Certain medical and surgical disease states—many found within the critical care environment—place patients at higher risk for development of TPTX and also limit physiological tolerance to TPTX once it occurs. Although physical examination and chest radiography generally confirm the occurrence of TPTX, physiological monitoring may herald the development of increasing intrapleural pressure. Expeditious recognition and pleural decompression are necessary to prevent the untoward hemodynamic and respiratory consequences of TPTX. Significant morbidity and mortality may arise from TPTX if treatment is unduly delayed, particularly in mechanically ventilated patients.